Tax Account Number: This is the number issued to identify
your business. You will find your account number on your monthly sales/use tax
report form.

Type of Tax: Select one of the following:

Sales Tax

Use Tax

Hotel-Motel Tax

Enterprise Zone

Occupational License Tax

Period: Indicate the tax period or periods during which an
overpayment occurred, such as "December 2000" or "January through December
2000."

1. Taxes Remitted: Enter the total taxes remitted as
reflected on your monthly sales/use tax return(s) filed for the tax period(s) in question.

2. Taxes Due, as Amended: Enter the amount that
should have been paid to the Revenue Division for the tax period(s) in question, as
opposed to the amount that was actually remitted. For example, your December 2000
return reflects that you paid $100. After discovering your error, you have
calculated that only $75 should have been paid. Enter the $75 on this line.

3. Refund Requested: The difference between what you
actually paid and what you should have paid. In the example above, you would enter
the difference between the $100 paid and the $75 that you should have paid. Enter
the $25 difference on this line.

Preferred Refund Method: Indicate whether you
would prefer a credit memo on your account or a refund check.

Reason for Requesting a Refund: Explain why you are requesting a
refund. If you need additional space, please attach an additional sheet or
letter of explanation.

NOTE: Any
"Claim for Credit or Refund of Taxes Paid" form on which a taxpayer is claiming a refund of
$1,500 or more must be notarized.